As a clinician, if you ever took a Mulligan course from Brian Folk, I suspect you will agree that the experience was positive, enjoyable, and eye-opening - and if you didn’t have a good laugh at some point on the course, you weren’t truly present.  As a friend, Mulligan teacher, co-teacher, colleague, and past member of the MCTA executive committee, he will be

missed.  Brian loved to travel, and many of you across the country benefited from his willingness to travel to clinics large and small to share his passion for teaching Mobilization with Movement techniques.  Although I never practiced side-by-side clinically with Brian, I have no doubt that many of his co-workers and patients benefited from his manual therapy expertise and enjoyed his light-hearted banter.

Those clinicians who became Certified Mulligan Practitioners under his tutelage would attest to his high level of enthusiasm and his extensive and broad-based manual therapy knowledge. Year after year, many clinicians who learned from Brian benefited from his willingness to spend countless weekends away from his wife Donna, friends, pet birds, and his spiritual home in San Diego.   Thinking about it, there are likely hundreds of patients who have also benefited from Brian in an indirect way.  Because of his teaching, clinicians treated their patients differently and more effectively as a result of learning from him.

 

Brian was a mix of Tommy and Dickie Smothers.  (Sorry if you don’t know these outspoken comedian brothers from the 60’s - look them up.)  Brian was a smart and serious Dickie Smothers at times.   But let’s be honest - he was one of the funniest and most entertaining people I’ve known - a Tommy Smothers, always ready to let his humor fly.  As I often experienced while co-teaching with him on courses, just like Dickie Smothers’ attempts to control his brother Tommy, attempting to rein-in Brian while co-teaching with him was quite comical and typically impossible.

 

Simply put, and paraphrasing the Beatles song “In My Life”:

“There are (places) and friends I’ll remember all my life - some have gone and some remain.   But of all these friends…….there is no one who compares with you.   I know I’ll often stop and think about you…… in my life, Brian’s been a good friend.”

Thank you, Brian, for being with us, although it seems like too short a time.

Rick

 

 

The last Mulligan Concept™ class Brian Folk taught was with me in Anchorage.  I didn’t need the help, but I asked him to come along for the ride.  He agreed and the weekend was an example of the good karma Brian brought everywhere.  We headed up a few days early because we both wanted to see Denali and try and catch the northern lights.  As we were driving up to Denali, Brian got pulled over for speeding.  After cracking a couple of jokes the cop just let us go, so we continued up to our hotel.  It was severely overcast and we couldn’t even see Denali or the sky.  We had a flight booked to fly around Denali and land on a glacier the next day but I doubted it would even be possible with the weather.  Around 2 AM Brian woke me up saying “check this out!”  There was an amazing northern lights show surrounding a crystal clear sky with Denali visible out the window!  Amazing.  The next day we both laughed as the pilot said, “Well gentleman, this is what you call a bluebird day up here – top 5% that you will ever get.”

Brian had become a master teacher at this point in his career.  As I watched him seamlessly crack jokes and make everyone in the entire class belly laugh, I also took a moment to appreciate his on-point delivery of all the key points most participants new to the Mulligan Concept™ need to hear emphasized.  Brian cared just as much about making people laugh as he did about teaching the Mulligan Concept because he had figured out that the two go together!  People learn more and stay engaged when they are having a good time!  Besides Brian Mulligan himself, I haven’t seen anyone teach quite like Brian Folk.

Brian and my paths first crossed in the PT clinic in 1996, and over the years we became great friends, brothers you might say.  He was a hilarious, thoughtful, driven, spiritual, loyal friend -much more than a colleague.  He battled CA with a grace that I will never forget.  He was endlessly positive and upbeat, even in the face of dire circumstances.  Brian brought people together, saw the common ground, and was a true collaborator who looked for the good in everyone.

The Mulligan Concept lost a true brother with Brian’s passing, he touched each one of us in so many positive ways and left this place better than he found it.  Until we meet again my friend!

Happy New Year from the NAMCTA!

By Julie Paolino PT, MS, ATC, MCTA

As you all know, 2021 was an interesting year for everyone, however as an organization, we would like to update you on some exciting news.  This past year we examined and accredited two new Mulligan Concept teachers in the United States, Amy Green Resler, and Jarrod Brian.

As a brief introduction, I asked them to tell them a little bit about themselves.

Jarrod Brian PT, OCS, CSMT, TPS, MCTA

How did you become interested in the Mulligan Concept?

A Mulligan Concept Lower Quarter course was the first class I took, one month after graduating from PT school.  I was immediately attracted to the hands-on, non-dogmatic approach to patient care.  It provided me as a young PT the opportunity to understand that some patients had the potential to experience instantaneous pain relief improvement in their function.  It became a cornerstone to my entire patient care approach.

When and where did you meet Brian Mulligan?

My first experience with Brian was at an Advanced course in Chicago.  I remember being very excited about the opportunity to learn from him directly.  It was a great course and really helped solidify my practice with the Mulligan Concept.

How long have you been practicing?

I have been a physical therapist for 18 years.

What are your special interests?

I consider myself a lifelong learner and this leads me down many trails.  However, I always seem to gravitate towards learning more about the various aspects and complexities of pain.  In the clinic, this focuses my interests on applying a biopsychosocial approach using pain-based mechanisms, individualized exercise plans, and manual therapy to influence patient outcomes.

Amy Green Resler DPT, MCTA

What type of practice do you work in?

I currently practice orthopedic physical therapy at the Naval Medical Center in San Diego, CA.

When did you first meet Brian Mulligan?

I met Brian Mulligan in 2003 in Honolulu, and since becoming exposed to Brian Mulligan and the Mulligan Concept have had daily successes with the Mulligan Concept that are too numerous to count!

What made you interested in teaching the Mulligan Concept?

I have been a “teacher” in many ways throughout my career and have always been passionate about teaching anatomy & biomechanics.  Since obtaining my CMP certification in 2006, I have assisted many of the NAMCTA instructors at their courses and have enjoyed combining my natural interest in teaching with my passion for the Mulligan Concept.

I loved the possibility of being part of an educational organization that is so committed to teaching this concept world-wide. As a full-time clinician, I see the exceptional and consistent benefits of this therapy with my patients. As a clinical instructor over the past 18 years, I have seen my student and colleagues become excited and empowered when they see the immediate results of applying Mobilizations with Movement. Becoming a member of the MCTA has always felt like a natural next step in my teaching career.

What are your special interests?

Clinically, I have a particular interest in understanding and treating the sacroiliac, hip, and lumbo-pelvic regions. I enjoy writing and I have written multiple evidence-based rehabilitation protocols for publication. In my free time, I love horseback riding, skiing, and volunteering for a hospice foundation and St. Jude's.

In Conclusion:

Having been one of the lead instructors in testing both Amy and Jarrod, I am excited about their addition to the MCTA.  They bring unique talents, clinical expertise, and passion to our team.  We wish them both success as MCTA instructors and look forward to their contributions to the Mulligan Concept.

Please join me in congratulating both Amy and Jarrod on becoming part of the Mulligan Concept Teachers Association!  Special thanks to Don Reordan and Pat Black for their assistance in the testing process.

 

Congratulations and Best Wishes to legendary MCTA Teacher Russ Woodman

In addition to bringing on two new members of the MCTA, I would also like to congratulate Russ Woodman who has retired from teaching Mulligan courses as of 2022.  On a personal note, Russ was my mentor for my undergraduate days at Quinnipiac College.  He was one of the first to introduce me to the Mulligan Concept.  His passion, enthusiasm, professionalism, and clinical expertise set him apart as one of the best in the physical therapy profession.  He is held in high regard within the physical therapy world and will be truly missed.  We wish him health and happiness in his next chapter of life with his bride, Phyllis, and his farm animals (which are too many to count).

Thanks Russ, you will surely be missed by all of us!

 

 

 

 

 

 

 

The 2021 study by Nguyen et.al., “Effects of Mulligan Mobilization with Movement in Subacute Lateral Ankle Sprains: A Pragmatic Randomized Trial” (HERE) demonstrated that Mobilization with Movement (MWM) can quickly and effectively increase ROM and function for subacute lateral ankle sprains in a little as 3 visits.

Quick Background: 

MWM manual therapy techniques involve passive accessory forces applied by a therapist, combined with active movement of the patient. MWM’s are always pain-free and are only used on ‘responders’. This means that if the technique is painful, it would not be used and the patient would be considered a ‘non-responder’.

Why is this study design important?

Before diving into the results, let's take a moment to appreciate the significance of this type of study.

The challenge of applying up-to-date evidence-informed care in the clinic is an ongoing struggle for busy clinicians. This topic was highlighted in a recent 2021 open-access editorial in the Journal of Manual and Manipulative Therapy (HERE).  Manual therapy thought leaders made 7 recommendations for shaping the 'next steps' in orthopedic manual therapy research.  One recommendation was the need for more pragmatic (effectiveness) randomized study designs.

Pragmatic research study designs focus on how an intervention performs under 'real-world' conditions. In other words, how can a busy clinician better apply evidenced-informed care? This is in contrast to interventions/treatments recommended from a traditional efficacy research study in which the trial was performed in an ideal/controlled environment. (HERE)

The pragmatic design of Nguyen et.al. 2021 is at the cutting edge of where research is headed and should be encouraging for all who use manual therapy as part of a multimodal plan of care.

Study Results:

The study examined an individual's response to Mobilization with Movement (MWM) for increasing pain-free dorsiflexion in subacute lateral ankle sprains. Instead of only studying one technique to treat the ankle, the pragmatic design allowed researchers flexibility to look for ‘responders’ to a variety of MWM techniques while determining the effectiveness of MWM’s compared to sham treatment for ROM and function.

The study consisted of 3 treatment sessions with measurements taken before and after each session.

Highlights from this study include: 

• 84% of the participants with subacute lateral ankle sprains were ‘responders’ to an MWM technique for immediately improving pain-free dorsiflexion ROM and function on the Y-Balance Test.
• Responders were found with MWM techniques targeting the tibiofibular joint (58%), talocrural joint (33%), and cubometatarsal joint (4%).  This suggests not all ankle sprains respond the same to MWM!
• The study further highlighted that being a ‘non-responder’ on the first treatment, did not mean that the individual would not be a responder on the next treatment. Several test subjects became ‘responders’ to MWM on the 2nd and 3rd sessions.
• 16% of all subacute ankle sprains were not appropriate for MWM. This potentially helps sub-group a population who may respond best to exercise and education without MWM manual therapy.

So What?: 

It could be argued that identifying responders to manual therapy, especially manual therapy that is pain-free and provides immediate results in ROM and function, is one of the best methods to treat subacute lateral ankle pain.

Being able to determine who is, and who is not, appropriate for manual therapy is more important than ever.  Manual therapy is not for everyone. Though being able to apply hands-on care to ‘responders’ may be an important key to quickly restoring ROM and function for subacute lateral ankle sprains.

Check out an upcoming Lower Quarter Mulligan Concept course if you are interested in learning how to provide MWM safely and effectively for ankle sprains. It will change your practice for the better!

Case History:

32 y.o. female of 5 foot 5 inches and 165 pound stature referred to skilled therapy with history of approximately 8 years of chronic mid back pain.  Insidious onset with pain being isolated to the T 4- T 9 area.  Pt reports daily pain that is best in the am and progresses throughout the day, can interrupt sleep, and is eased by 50-75% with resting on the couch for 30 minutes.  She has a sitting profession and sits between 7-10 hours per day including her commute.  Negative x-ray findings.  She reports seeing 3 bouts of previous skilled therapy that included chiropractic (x 1) and physiotherapy (x 2).  She states she had approximately 50% improvement in pain and no improvement in functional level with all therapies.  Therapies that she described included: thrust joint manipulation, passive modalities, active weight-bearing and isotonic exercises focused on the parascapular area as well as stretching for the anterior chest wall.  Denies smoking and 1-2 alcoholic drinks per week.  Exercise regimen was 1-2x/ wk walking 2-3 miles with her neighbor. Patient is right handed.  She was referred to my office via community recommendation.

Evaluation:

The patient was not in distress, did not fear her condition, and did not report any signs associated with depression.  She believed that her posture as some inclusion in her symptom presentation and reported that movement, heat, and over the counter anti-inflammatories did help, although minimally.  She had sought consult with a cosmetic surgeon regarding breast reduction on the recommendation of her primary care as there was the possibility of her pain being correlated to her breast endowment size.  She stated she viewed this as a last resort and was not actively seeking this surgical direction at the time of the evaluation.

Objective findings included:

• Vitals
  • Resting HR: 74
  • BP 124/ 88
• Tenderness to palpation
  • VAS 3-5/10 report of pain to the T 5- T 9 area
• Range of Motion
  • AROM screen – Pt willing to move
    • Flexion: WNL – 42*
    • Extension: WNL – 35*
    • Lateral Flexion: WNL – Bilaterally 25*
  • Limited and painful AROM Thoracic rotation performed in sitting with arms crossed and arms stacked extended held at 90 flexion (measured with iPhone inclinometer
    • L: Arms X- 24* w/ central pain. Increased pain w/ overpressure
    • R: Arms X- 18* w/ left sided pain. Increased pain w/ overpressure
    • L: Arms extended – 18* with central pain
    • R: Arms extended – 15* with left sided pain
  • Resistive strength testing
    • General screen performed in sitting
    • Parascapular testing performed in prone
      • Horizontal ABD: L 4/5 without pain; R 4-/5 without pain
      • 90/90 ER: B 4/5 without pain
      • Prone 135: L 4/5 without pain; R 4-/5 without pain
    • Functional Movement Assessment
      • Apply’s Scratch test: WNL
      • Full Forward Elevation: WNL
      • Hands behind head: WNL
    • Passive joint motion exam
      • Pain R2 with Central PA pressures: T 5- T 9
      • Pain R2 with Left Unilateral Pressures: T 5 – T 9
      • Pain 1 with R 1 with R Unilateral Pressures: T 5 – T 9

After review of subjective and objective findings, Mobilization with Movement as the first attempt to address her comparable sign of thoracic spine symptoms and was selected for three main reasons:

1. She presented with no red or yellow flags
2. Her symptoms presented in what can be deemed a “mechanical” environment. They would be produced, altered or changed; she was not in distress, and her symptoms were stable
3. Her previous experience with treatment suggested not attempting the same types of treatment. But rather, attempting treatments that had not been applied or focused on different comparable signs.

Treatment was applied as explained in Manual Therapy: NAGS, SNAGS, and more. 6^th edition.

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Treatment Session 1:

The treatment choice was explained to the patient and she consented for treatment. Six repetitions of through the full active range were achieved with overpressure provided and accepted during each repetition for both right and left rotation in sitting.  Immediate post-treatment reassessment demonstrated right thoracic rotation with arms crossed 35* and left rotation with arms crossed 38*.  The patient was then instructed in AROM exercises for 5 repetitions bilaterally every other hour until her follow up appointment.  PILL response was explained to the patient.

 

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Treatment Session 2:

Upon return to the clinic, patient reported compliance with the above program and demonstrated full maintained AROM bilaterally for thoracic rotation with mild pain report at end range of right rotation. Her VAS report was 0-2/ 10 for the past 48 hours.  Three sets of 10 repetitions of symptom-free motion MWM’s were applied to both right and left rotation.  The patient was then shown a self MWM technique utilizing a belt to mimic the manual application. Instructions for five repetitions each direction three times per day were given.

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Treatment Session 3:

Patient returns 1 week after treatment session 2 and reported compliance with the instructed HEP and no pain for the past 5 days in her thoracic pain during ADL and work activities. A parascapular program with resistive bands and isotonics were issued in clinic including resistive rows, prone horizontal ABD, prone 90/90 ER, and serratus push ups.  All exercises were tolerated with fatigue only in the clinic.

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Treatment Session 4:

The patient returned to the clinic in 2 weeks reporting good compliance with the HEP and 0/10 pain since the complete of treatment session 3. Re-evaluation demonstrated full resolution of all objective findings mentioned previously.  Spoke with patient for more than 10 minutes regarding future maintenance of exercises, prolonged posture considerations, education on poor likelihood of correlation with breast tissue endowment and returning to skilled therapy as needed.  She was then discharged to her established program.